Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Tulsa, Llc during CMS and state inspections, most recent first.
A resident with a recent amputation and multiple comorbidities did not attend a scheduled follow-up podiatry appointment because staff failed to notice the appointment on the dashboard, despite transportation being arranged. This oversight led to a delay in therapy, as the missed appointment would have provided necessary orders for weight bearing, impacting the resident's care before discharge.
The facility failed to securely store medications on halls 200 and 300. An LPN on hall 300 repeatedly left the medication cart unlocked and unattended during medication passes, contrary to the facility's Medication Storage policy. On hall 200, a medication cart was also found unlocked and unattended. The DON confirmed that medication carts must remain locked at all times.
A facility failed to maintain a catheter bag and tubing to prevent infection for a resident with an indwelling urinary catheter. The care plan required the catheter bag to be attached to the bedside and not touch the floor. However, observations showed the catheter bag and tubing on the floor. Interviews with a CNA, an LPN, and the DON confirmed that staff were instructed to keep the catheter bag off the floor.
The facility did not follow the prescribed menu for residents on pureed diets, substituting pasta for rice and omitting the egg roll. The kitchen staff believed a starch, protein, and vegetable were sufficient, while the dietician stated that all menu items contribute to nutritional value and should not be altered without consent.
A facility failed to follow hospital discharge orders for a resident's enoxaparin medication, reducing the prescribed 30-day course to three days based on a verbal order from an NP. This led to the resident receiving insufficient anticoagulation treatment, contributing to a cerebrovascular accident and subsequent death. The deficiency was due to a lack of proper confirmation and documentation of the medication order change.
Missed Medical Appointment Results in Delay of Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident attended a required medical appointment following hospital discharge. The resident, who had a history of amputation, peripheral vascular disease, and end stage renal disease, was discharged from the hospital with instructions to follow up with podiatry two weeks after surgery. The resident was moderately impaired for daily decision making, as indicated by a BIMS score of 12. Documentation showed that the resident preferred to have the surgeon remove sutures, and an appointment was scheduled for this purpose. However, the appointment was missed because staff did not see it on the dashboard, resulting in the resident not being transported to the appointment as planned. The missed appointment led to a delay in therapy, as the resident's representative stated that the appointment would have provided necessary orders for weight bearing as tolerated, which could have allowed the resident to receive more therapy before discharge. The social services director and DON confirmed that the appointment was scheduled and transportation arranged, but the oversight in not noticing the appointment on the dashboard caused it to be missed. Although the physician was notified and provided instructions to remove the sutures and reschedule the appointment, the resident was discharged before the rescheduled appointment could occur.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored on halls 200 and 300, as observed during a survey. The Medication Storage policy requires all drugs and biologicals to be stored in locked compartments, and during medication passes, medications must be under the direct observation of the administering person or locked in the medication storage area/cart. On multiple occasions, an LPN on hall 300 left the medication cart unlocked and unattended while entering resident rooms. Specifically, on December 9, 2024, the LPN left the cart unlocked at 4:06 p.m. and 4:07 p.m. before locking it at 4:10 p.m. Similarly, on December 10, 2024, the LPN left the cart unlocked at 9:10 a.m. before locking it at 9:11 a.m. Additionally, on December 11, 2024, the medication cart on hall 200 was observed to be unlocked and unattended at 2:00 p.m. An LPN later locked the cart at 2:20 p.m., acknowledging the protocol to keep the cart locked but was unsure why it was not locked. The DON confirmed that medication carts must remain locked at all times.
Failure to Maintain Catheter Bag and Tubing to Prevent Infection
Penalty
Summary
The facility failed to maintain the catheter bag and tubing to prevent infection for a resident with an indwelling urinary catheter. The resident had diagnoses including obstructive and reflux uropathy. The care plan specified that the catheter bag should be attached to the bedside to drain and ensure it is a closed drainage system, not touching the floor. However, observations on two occasions showed the catheter bag and tubing laying on the floor beside the bed. Interviews with a CNA and an LPN confirmed that staff were instructed to position the catheter bag on the side of the bed and keep it from touching the floor. The DON also stated that catheter bags and tubing were to be kept off the floor.
Failure to Follow Prescribed Puree Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, as observed on December 10, 2024. The menu for the day included sweet and sour chicken, stir-fried vegetables, rice, and an egg roll. However, the kitchen staff substituted pasta for rice and omitted the egg roll from the pureed meals. The kitchen manager and chef both stated that they believed a combination of a starch, protein, and vegetable was sufficient for pureed diets, and they did not typically include bread or egg rolls in these meals. The dietician later confirmed that the menu should not be altered without their consent, as each component contributes to the nutritional value of the meal, regardless of texture. Substitutions are allowed only with the dietician's approval, and nothing should be omitted from the menu.
Failure to Follow Hospital Discharge Orders for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a nurse practitioner did not give a verbal order to reduce all enoxaparin orders from acute care hospitals to a three-day course, which led to a deficiency in the care provided to a resident. The resident, who had a history of atrial fibrillation and thrombophilia, was discharged from an acute care hospital with a 30-day enoxaparin order. However, the facility only administered the medication for three days, as per the verbal order given by the nurse practitioner to an LPN. The resident was admitted to the facility with a discharge medication list that included enoxaparin injections to be administered once daily for 30 days. Despite this, the facility's medication order was altered to a three-day course without confirmation from a physician or nurse practitioner. This resulted in the resident receiving only three doses of enoxaparin, which was insufficient according to the original hospital discharge orders. The deficiency was further compounded by the lack of awareness among the facility staff regarding the verbal order to reduce enoxaparin to three days. The LPN responsible for entering the admission orders into the electronic health record did so based on the verbal instruction from the nurse practitioner, without any documentation or confirmation from a supervising physician. This oversight led to the resident experiencing a cerebrovascular accident, ultimately resulting in their death.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tulsa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Hills Care And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| The Cottage Extended Care | 1.9 mi | ★★★★★ | 0 | 0 |
| Senior Suites Healthcare | 1.9 mi | ★★★★★ | 15 | 0 |
| Montereau, Inc. | 3.4 mi | ★★★★★ | 7 | 0 |
| Aspen Health And Rehab | 3.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.